Gynecologic Surgery Research: Postoperative Cognitive Dysfunction and Pelvic Organ Prolapse Surgery

New research on the incidence of postoperative cognitive dysfunction in older women after pelvic organ prolapse surgery was published by a team of researchers from the Division of Urogynecology in the Department of Obstetrics, Gynecology, and Reproductive Sciences at UPMC Magee-Womens Hospital. Mary F. Ackenbom, MD, assistant professor in the Department, was the lead author on the study published in August in the International Urogynecology Journal.

Postoperative cognitive dysfunction (POCD) is characterized by impairments in a patient's concentration, memory, and information processing ability that is transient, with most cases resolving in several weeks to several months. POCD is relatively common after surgery in older adults. Long-term consequences are not fully appreciated, but POCD is known to increase morbidity and mortality in the postoperative period. It can lead to lengthier recovery periods, among other detrimental effects. The literature on POCD prevalence for noncardiac surgeries varies from 7% to 26%.

Little is known about the prevalence and effects of POCD, specifically on older women who undergo pelvic organ prolapse surgery. However, surgical remediation of pelvic organ prolapse (POP) is on the increase and is expected to continue an upward trend for the foreseeable future. Since the majority of surgeries for POP are performed on older adult women, this patient population may be more at risk for POCD, and thus is a potential factor that should be incorporated into the decision to have surgery. 

Study Aims

Dr. Ackenbom and colleagues’ study had two specific aims. The first was to determine the incidence of POCD after pelvic organ prolapse surgery two weeks after the procedure. The second aim was to try and uncover specific factors or patient characteristics associated with cases of POCD. This prospective study included a cohort of women age 60 years and older undergoing surgery for POP.

“From other surgical studies in the literature, we know POCD, to varying degrees, can affect a significant percentage of patients undergoing surgery. I believe it is often an underinformed risk to surgery that patients may not fully appreciate. Being that the aging population is growing and subsequently more older women will undergo prolapse surgery, we owe it to our patients to better understand this potential complication, how frequently it occurs, and who may be at greatest risk. POCD can have profound consequences on individuals. We need a better understanding of it in order to best counsel our surgical patients," says Dr. Ackenbom.

Overview of Findings

Patients recruited for the study were subjected to a comprehensive neurocognitive testing battery to establish their baseline cognitive function. The same testing was then conducted two weeks after the individual had their surgery, while clinical outcomes measures were documented six weeks after surgery. The women also were screened for signs and levels of frailty. For the group of women who completed testing before and after surgery (n=72), the median age of women in the study was 72 years. 

Participants were screened for delirium at multiple points during the first postoperative week, specifically at days 0, 1, 3, 5, and 7. Postoperative delirium, which should always be a concern in older surgical patients, can present in a symptomatically similar manner as POCD.

“Upon completion of the data analysis, we determined that 33% of our study participants exhibited POCD at the two-week postoperative interval. This turned out to be a higher percentage than what we expected. We anticipated seeing an incidence of 20% based on what has been reported in other studies on similar surgical populations.,” says Dr. Ackenbom.

One potential reason for the increased rate of POCD was the older age of the patients in this study.

"Then again, there is precedent in the literature, as we point out in our discussion, for this high of a POCD rate. Still, it is concerning, regardless of whether the patients are older or may have some level of frailty. These patients are more frequently opting for this surgery, so if they do indeed experience higher rates of POCD, or more severe manifestations, we must find ways to mitigate the potential for those undergoing POP surgery, says Dr. Ackenbom.

While more research will need to be conducted to gain a clearer picture of the individual risk factors, specific phenotypes, and even the long-term consequences to cognitive health and physical well-being from POCD, the findings from Dr. Ackenbom and colleagues’ study may have implications and lead to additional research in other surgical disciplines or for specific procedures.

Contributing research team members from the Division of Urogynecology at UPMC Magee included Lindsey Baranski, MS, and Halina Zyczynski, MD. Meryl A. Butters, PhD, from the Department of Psychiatry; Esa M. Davis, MD, MPH, FAAFP, from the Department of General Internal Medicine; and Kaleab Z. Abebe, PhD, from the University of Pittsburgh Center for Research on Health Care Data Center also contributed to the study.

Reference

Ackenbom MF, Butters MA, Davis EM, Abebe KZ, Baranski L, Zyczynski HM. Incidence of Postoperative Cognitive Dysfunction in Older Women Undergoing Pelvic Organ Prolapse Surgery. Int Urogynecol J. 2020. Epub ahead of print.